Falcon House Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question Good. At this inspection the rating has changed to Requires Improvement. This meant people’s outcomes were not consistently good, and people’s feedback confirmed this.

The provider was in breach of legal regulation in relation to consent.

This service scored 42 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team did not make sure people’s care and treatment were effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

The management team had not ensured people and those close to them were involved in regular assessments and reviews. This left a shortfall in ensuring people’s opinions were respected, listened to and implemented as part of their care planning.

Most people and relatives we spoke with could not remember whether they had had an assessment prior to moving into the service. Documents written by health and social care staff had not been used to create meaningful care plans for people. People and their relatives had not been fully consulted in care planning.

People living with specific clinical conditions did not have care plans and risk assessments in place for these. For example, one person lived with Parkinson’s and there was no care plan in place for this. This left people exposed to the risk of staff not understanding their specific needs.

We reviewed care plans and risk assessments for people requiring support with falls risk management. The risk rating assigned to individual people was not reflective of their current level of mobility and risk. The review details for each care plan showed these had not been updated following an incident or event. These care plans and associated risk assessments showed a lack of robust guidance for staff, with actions required or taken to mitigate risk not accurately recorded.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

For example, diabetes risk was not assessed and mitigated safely for people. Multiple people required support to manage type two, diet-managed diabetes, where their sugar intake should be kept as low as possible. The information on the food and nutrition plan in the kitchen was contradictory to the diet sheets showing food given to people. These included many foods high in sugar, such as cereals, biscuits and cakes. Best practice guidance on diabetes management was included in people’s care plans but was not being followed by staff to ensure people received safe, supportive care.

We saw staff had a good understanding of people and their individual needs, although the wider care team had not signed to say they had read and understood people’s individual care plans and risk assessments. This left people at risk of harm, as staff might then lack knowledge of what immediate action to take if a person’s needs appeared to have changed.

The management team did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Where people had been assessed by an external team prior to moving into the service, we saw this information had not been incorporated into their care plans and risk management records. For example, a person living with an advanced progressive condition had no specific care plan associated with this. This left the staff team unclear as to what the support needs of this person would be, and how to recognise any changes which would require external review.

Although people had a person-centred care plan, ‘This is Me’, in place, the information in this section was incorrect, even though they had been regularly reviewed. There was a lack of consistent approach maintained between services, leaving people exposed to the risk of not being effectively supported with their identified needs.

People were supported to access their GP, dentist or optician regularly. Feedback from people and relatives was positive regarding this being accessible for them when required. One person said, “A GP visits frequently and will come immediately if necessary.” Another person said, “I have just seen an optician and got some new glasses.” However, we saw information from these visits was not being used to inform and update care plans for people.

The management team did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not being supported to maintain their personal cleanliness. Daily records for people showed that limited personal care was being provided for people. The bathing and shower chart for the service lacked flexibility for people’s personal choice and was not being followed by staff. Some people were observed to be unkempt and requiring their hair washing. Where people might be resistive to personal care, this was not clearly recorded in their care plans. One person said, “I get a shower once a week, sometimes less but I don’t mind that. I have a good strip wash.” A relative told us, “My family members’ toiletries get used very slowly. They would have used far more when they lived at home.”

Changes in people’s presentation, emotional state or distress, which might indicate a deterioration in their health or wellbeing were not being recognised. People were not being supported to access emergency health care if needed to ensure a fully wrap around care experience. For example, where a person was exhibiting changes in their clinical condition, the management team had not promptly shared this with the covering GP practice to ensure they could access prompt care and treatment.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent or that they met both clinical expectations and the expectations of people themselves.

Feedback we received from people indicated the service worked in partnership with external agencies. However, we found the care plans, risk assessments and daily records for people had not been regularly updated when a review had taken place. This left people living at Falcon House with potential unmet needs.

We found a lack of therapeutic, meaningful engagement available for people. People and relatives gave mixed feedback about the lack of meaningful activities which were offered. During our inspection, there were activities offered in the form of a quiz, chair-based exercise class and a singer. However, in the main, people were observed to be seated in the communal lounge for extended periods of time with a lack of repositioning or interaction with staff.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

People were not always supported to understand consent, what being safe meant to them, and how to raise concerns when they did not feel safe or they had concerns about the safety of other people.

One person spoke to us about consent, they said, “The staff usually ask me before doing things but don’t always knock before coming into my room.”

There was limited understanding shown by the management team of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). We found the requirements of the MCA were not being consistently met and applied to ensure people’s rights were being upheld. Records of urgent DoLS applications to the local authority had not been followed up by the management team after an extended period of time. Many applications had holding letters, so people were placed at risk of being subjected to unnecessary restrictions. Some people would be at risk if they did not have continuous supervision and control, where this was the case, we found a lack of application of suitable Deprivation of Liberty Safeguards. These safeguards ensure people who cannot consent to their care arrangements in a care home or hospital are protected if those arrangements deprive them of their liberty.

There was a lack of information to support staff in communicating with people about their choices where they might not use verbal communication. The management team had not included objects of reference, visual aids or equipment to support this. Care records did not include how either through verbal or non-verbal means people were able to refuse or give consent for specific decisions.